Brazos Valley Vaccine HUB Volunteer Application

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Name

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Email

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Primary Address

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Primary Phone

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Birthdate

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Organization Affiliation ("None" if not affiliated)

Please let us know if you are volunteering as a member of another organization
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Spanish Speaking

Spanish speakers are welcome to sign up for any available shift or to serve solely as interpreters.

Other Languages Spoken

Please list all fluent languages spoken
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American Sign Language

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Medical Professional

Medical professionals are able to serve as vaccinators, vaccinator assistants, and observers for post vaccination waiting period.

Medical License # (Required for Vaccinators)

Vaccinators must have active medical license to administer the vaccine. • Licensed Vocational Nurse • Registered Nurse • Nurse Practitioner • Paramedic (excluding EMT basic) • Medication Aide • Pharmacist • Physician • Physician Assistant • D.D.S. Dentist

Medical License Expiration Date

Vaccinators must have active medical license to administer the vaccine.
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Willing to Volunteer in Person (PPE provided, following COVID Guidelines)

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Computer Proficiency

Availability

Planned hour of operation are 7:00am-5:30 pm Monday-Friday, but this is subject to change.
 MorningAfternoonEvening
Mon
Tue
Wed
Thu
Fri
Sat
Sun
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Feeding Partners-May we contact you to provide a meal for staff/volunteers

Volunteers will be offered bottled water during the shift. Lunch will be provided for volunteers working double shifts.
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Received COVID Vaccine Dose 1

Vaccine will be available to volunteers, but is not guaranteed before your shift. Access to the vaccine for volunteers is based on availability of the vaccine.
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Received COVID Vaccine Dose 2

Vaccine will be available to volunteers, but is not guaranteed before your shift. Access to the vaccine for volunteers is based on availability of the vaccine.

COVID Recovered

Other Services

Please let us know of any other service you would like to provide.
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Terms and Conditions

As a St. Joseph Volunteer working at the Brazos County Community COVID Vaccine HUB, you agree to:
• Self-screen at home prior to coming into any building. Refer to the signs & symptom checklist
• Wear your face covering at all times including when entering and exiting the building
• Wear eye protection when interacting with team members or patients
• Maintain social distancing (minimum of 6 feet) at all times
• Wear gloves if required for your assignment
• Practice hand hygiene by washing your hands and hand sanitizing frequently throughout your shift
• Not eat at your volunteer location as this would involve removing your face covering
• Clean your area at the end of your “shift” with antiseptic wipes
• No wearing of hats, sunglasses, or earbuds when volunteering
• No strong perfumes/artificial smells
• Nails must be clean and NOT ARTIFICIAL
Please read the following and sign indicating your understanding and agreement:
By signing below, I confirm that I have read, understand, and agree to the terms and conditions above.

This agreement does not constitute any employment agreement between me and CHI St. Joseph Health. The decision to volunteer with CHI St. Joseph Health to work in the Brazos County Community COVID Vaccine HUB is my own. I have not been forced or coerced to do so.

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Terms and Conditions

CONFIDENTIAL INFORMATION

In fulfilling our duties, we see a wide range of confidential information. We treat information about our patients, residents, members and others we serve as confidential and proprietary information. This means that St Joseph Health does not share this information with the public and is careful to share with business partners only when they have a need to know the information. Confidential and proprietary information is maintained in different forms such as paper records, electronic records, films and verbal discussions. Sharing this information improperly can harm our mission, individuals in our care and our business partners. We have specific policies and procedures to maintain and protect the confidentiality of individuals we serve, employees and organizational information. For review of these policies, you may request St Joseph Health’s Privacy, Security and Confidentiality policies.

Information about Patients, Residents, Members or Others We Serve

Individuals we serve expect us to maintain the confidentiality and security of their health information. A St Joseph Health we not only follow the national and state privacy and confidentiality laws such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Breaking these laws may result in civil or criminal penalties of St Joseph Health and/or the responsible individuals.

The employees, affiliated physicians and health care partners of St Joseph are permitted to use or disclose protected health information (PHI) only to serve and care for our patients, residents, members and others in our care. We do not use, disclose, or discuss confidential information with others unless the patient, resident, member or other individual in our care authorizes the release of his/her information or we are required or authorized by law to release the information. St Joseph Health and the individuals who improperly use or disclose confidential information may face civil and/or criminal penalties for breaking these laws. In addition, employees may face disciplinary action up to and including termination.

Employee Information

We keep employee information confidential by following human resources policies and state and federal laws. Employee personal information includes wage and salary information, employment agreements, employment history and status, Social Security numbers, and financial and banking information.
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Terms and Conditions

Waiver for Injuries/Damages

I understand that in consideration of being permitted to volunteer at CHI St. Joseph Health does hereby release and forever discharge the CHI St.
Joseph Health and any and all employees thereof from all liability which I, or my executors, administrators, or assigns, may, or can have by reason of my contracting any communicable disease or diseases as a result of such volunteer activities, and/or personal injuries or property loss incurred during such activities.

If you are injured while performing your duties and the injury is deemed as a result of your duties or environmental hazard, you will be taken to the Emergency Room to be assessed and treated by CHI St. Joseph Health. If you have insurance, they will file on it and cover any out of pocket expenses. If you become injured or are ill not as a result of your duties or an environmental hazard, you may still be taken to the Emergency Room (if required), but you will be responsible for all incurred charges.

***I understand that signing this form constitutes a legal signature confirming that I acknowledge and agree to the Waiver Statement.
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Terms and Conditions

VACCINATIONS FOR VOLUNTEERS: While it is possible that a volunteer may be allowed to receive a vaccination from leftover amounts at the end of a shift on which they work, there is no guarantee or promise that this will happen. Vaccine supplies are strictly limited by state allocation. Please consider this if you are planning to travel to the hub from outside the Brazos Valley.
About Brazos Valley COVID Vaccine HUB
Our mission is to mobilize volunteers and the generosity of donors to assist in the COVID-19 vaccination efforts in the Brazos Valley through the collaboration of a multi-agency effort.
Visit hub
Brazos Valley COVID Vaccine HUB
3232 Briarcrest Dr
Bryan
Brazos
United States
Brazos Valley COVID Vaccine HUB logoBrazos Valley COVID Vaccine HUB